Facial Cellulitis in Older Man Presents Variability in Diagnosis

Figure 1. Right neck subdermal plaques with focal overlying ulceration.

Presentation: An 88-year-old male with an extensive medical history, including diabetes mellitus, presented to a tertiary care institution after being unsuccessfully treated for facial cellulitis. Three months prior to admission, he had developed a pruritic, edematous, and erythematous lesion on his left chin after he nicked himself shaving. He was treated on an outpatient basis by his primary care physician with a combination of topical and oral antibiotics. He was seen by dermatology, and superficial biopsies were performed, revealing only cellulitis with necrosis.

A month after the initial symptoms developed, the patient noted progression and was seen in an outside hospital. A facial CT scan was performed and was consistent with cellulitis without fluid collection. The patient was started on ceftriaxone and ten days of vancomycin with modest improvement of his facial swelling and edema. Despite treatment, he was admitted with worsening facial symptoms, development of pain, and serosanguinous drainage.

Blood cultures were negative, and wound cultures revealed rare mixed gram-positive flora. No leukocytosis or eosinophilia was present. After four days with no improvement, he was transferred to the tertiary care institution for otolaryngology evaluation.

(click for larger image)

Physical examination revealed honey-colored exudate over the lesion, with extension to the right side under the chin and a right submandibular mass concerning for pathologic cervical lymphadenopathy. Erythema and peripheral crusting with central ulceration at the area of the left jawline and the lower lip (Figure 1) were present. There was a subdermal plaque at the level of the left thyroid cartilage with medial soft tissue fullness and a firm, mobile plaque with overlying erythema and minimal ulceration. There was significant concern for malignancy due to the fungating appearance with subcutaneous extension. Deep biopsies of the left facial lesions and a fine needle aspiration of the right submandibular mass were performed.

—Tristan Klosterman, MD, Adam Bied, MD, Ramsay Farah, MD, and Amar Suryadevara, MD, Upstate Medical University, Syracuse, N.Y.

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